Provider Demographics
NPI:1639670011
Name:OPTIC GALLERY NELLIS LLC
Entity Type:Organization
Organization Name:OPTIC GALLERY NELLIS LLC
Other - Org Name:OPTIC GALLERY NELLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIS
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEATY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-820-2020
Mailing Address - Street 1:111 N NELLIS BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-6010
Mailing Address - Country:US
Mailing Address - Phone:702-820-2020
Mailing Address - Fax:
Practice Address - Street 1:111 N NELLIS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-6010
Practice Address - Country:US
Practice Address - Phone:702-820-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty